1. Dual Diagnosis Mental Health and Behaviour Problems in People with Intellectual Disabilities
CORE CURRICULUM

2. MENTAL HEALTH AND BEHAVIOUR PROBLEMS

3. INTELLECTUAL DISABILITY MENTAL HEALTH & BEHAVIOUR DISORDERS
DUAL DIAGNOSIS
Definition
INTELLECTUAL DISABILITY
MENTAL HEALTH & BEHAVIOUR DISORDERS
FACTS
1. High prevalence of Mental Health and Behaviour Disorders in ID.
2. Greater difficulties in assessment and evaluation.
3. Greater difficulties in treatment interventions.
4. Mental health and behaviour disorders undermine the persons´ quality of life.
5. Difficulties in evaluation and treatment lead to greater frustration and stress in carers.
6. Despite the difficulties, mental health and behaviour disorders can be and SHOULD be diagnosed and receive specific treatment.

4. MENTAL HEALTH DISORDERS IN PEOPLE WITH DUAL DIAGNOSIS
SAME CAUSES
GENETIC PREDISPOSITION
Prader Willi S Psychosis
Downs S Depression
LIFE EVENTS
Death of a close relative
Job change / Economics problems, etc
SAME DISORDERS
ANXIETY DISORDERS
Panic Disorder, Phobias, TOC, etc.
AFFECTIVE DISORDERS
Depression, Bipolar Disorder, etc
PSYCHOTIC DISORDERS
Schizophrenia, Delusional Disorder, etc
SAME SYMPTOMS
ISOLATION
ANXIETY
INSOMNIA
WEIGHT LOSS
ANHEDONIA
SADNESS
HALLUCINATIONS
DELUSIONS
INHIBITION
PARTICULAR SIGNS AND PRESENTATIONS
Self-injury and hetero-aggression
e.g. In non-verbal patients constant cries can reveal fear
e.g. In non-verbal patients constant hitting of the ears can be a sign of hallucinations

5. MENTAL HEALTH DISORDERS IN PEOPLE WITH DUAL DIAGNOSIS
DETECT EARLY SIGNS AND SYMPTOMS
Changes in routines, likes and dislikes
Sleep and feeding patterns
Unmotivated important weight changes
Isolation
Apathy
Unmotivated cries, smiles or laughs
Soliloquium (a person talking to him-herself )
Externalised aggression
Self-injury
Sadness, expansive or inappropiate affect
Intriguing and/or worrying behaviors
Etc
OBSERVATION
TALK TO THE PATIENT CONSULT YOUR TEAM

6. BEHAVIOUR DISORDERS IN PERSONS WITH DUAL DIAGNOSIS
BEHAVIOUR DISORDERS DEFINITION
PRODUCT OF MENTAL HEALTH DISORDERS AND PHYSICAL CONDITIONS
BEHAVIOUR PHENOTYPES
NON ADAPTIVE BEHAVIORS
Different Mental Health Disorders can provoke symptoms that may be confounded with Behaviour Disorders. Disturbing behaviours that are new, unusual, with an abrupt onset must be explored and the possibility of being a product of a mental health disorders have to be considered. Some times disturbing behaviours can be caused by physical conditions that involve pain. Again, a medical screening is needed when sudden unusual behaviour disturbances appear.
Some genetic syndromes are characterised by well established behavioural patterns that are inherent to these conditions i.e. Prader Willi S. & Hyperfagia. These behaviours are difficult to treat and the strategies used should be different. Note, that many behavioural phenotypes represent positive patterns and can be considered as advantages or talents i.e. puzzle solving, friendly attitudes or ability for calculations.
Inappropriate behaviours that are learnt and used in order to get a goal, although the chances of getting that goal are reduced by the behaviour. These behaviours can be modified using psychological interventions and techniques.
BEHAVIOUR DISORDERS
SELF-INJURY
AGGRESSIVENESS
STEREOTYPY
MANIPULATION
SHOUTING
CRIES
DESTRUCTIVE BEHAVIOUR
OPPOSITIONAL ATTITUDE
EXPLICIT SEXUAL CONDUCT

7. CONCLUSIONS
1. Mental health problems and behaviour disorders are frequent in people with ID.
2. Same symptoms can be produced by different mental health conditions and can also be manifested by different signs in different patients or in different circumstances.
3. Mental health conditions, behaviour disorders, symptoms and signs collate together in a confusing contellation in persons with Dual Diagnosis. Take into account all the possibilities.
4. Mental health and physical medical conditions, genetic syndromes and non-adaptive behaviours can be the cause of different disturbing behaviours.
5. When sudden, inexplicable, unusual behaviours appear, consider different options before reaching a conclusion.
6. Normally the behaviours and the symptoms are uncontrollable. To complain or to argue with the patient only make things worse. Look for your team support. If you feel overwhelmed try to look for new formation opportunities.

8. QUALITY OF LIFE
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9. QoL: A POLYSEMIC CONCEPT
Mass-Media meaning
a universal ideal of high quality of most material and most marketable
areas of life (i.e. objects owned, success in career, money to spend,
social environment, holidays and free-time, physical performances)
objective
a person’s life conditions as they appear to an external observer.
Hetero-evaluation.
Medical
meaning
the patient’s perception of his own health status
(aspects of life related to wellbeing and functioning)
subjective
the individual perception of satisfaction with the ‘being in the world’.
It can be evaluated only through the person’s opinion. Auto-evaluation.
Bertelli M. e Brown I. Quality of Life for PWID. Current Opinion in Psychiatry, 2006; 19:

10. QoL vs SUBJECTIVE WELL-BEING
Subjective well-being concerns itself primarily with affective states, positive or negative.
QOL implies a broader assessment and although affect-laden, it represents a subjective evaluation of oneself and one's social and material world.
The exploration refers to those areas of life that are applicable to anybody’s life.
Orley J., Saxena S., Herrman H. Quality of life and mental illness. Reflections from the perspective of the WHOQOL. BJP, 1998 10

11. GENERIC QOL VS HR QOL
Generic: subjective modulation in those areas that are applicable to anybody’s life
Health-Related: mixture of clinical or dysfunctional aspects, compared to normality
Bertelli M. e Brown I. Quality of Life for PWID. Current Opinion in Psychiatry, 2006; 19:

12. QoL: DIMENSIONS • Importance attributed by the individual
• Satisfaction perceived by the individual
• Opportunities available
• Choices made by the individual
Brown I. et al., Centre of Public Health, University of Toronto, 1995

13. BELONGING Connections with one's environment.
THE 9 AREAS OF LIFE OF THE QOL-IP
- PHYSICAL
- PSYCHOLOGICAL
- SPIRITUAL
BEING
Who the patient is as a person.
- PHYSICAL
- SOCIAL
- COMMUNITY
BELONGING Connections with one's environment.
BECOMING
Achieving personal goals, hopes and aspirations.
- PRACTICAL
- LEISURE
- GROWTH
Brown I. et al., Centre of Public Health, University of Toronto, 1995

14. External Assessor Questionnaire person herself other person
QoL: MODE OF ASSESSMENT
Direct interview
Proxy Questionnaire
External Assessor Questionnaire
person herself
other person
Bertelli M. e Brown I. Quality of Life for PWID. Current Opinion in Psychiatry, 2006; 19:

15. VULNERABILITY AND RESILIENCE
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16. Protective environment
Adversity
Vulnerability
Resilience
Factors in the child’s environment acting as buffers to the negative effects of adverse experience
Characteristics of the child, the family circle and wider community which might threaten or challenge healthy development
Characteristics that enhance normal development under difficult conditions
Life events or circumstances posing a threat to healthy development

17. + Poverty Well-Being (Duration & Depth) Accumulated Vulnerability &
exposure
across the
life-course
to a wide
range of
material
&
psychosocial
hazards
(e.g., toxins,
uncertainty,
adverse life events)
Vulnerability &
Resilience
Biological
(genetics,
early development)
Psychosocial
(human capital,
social affiliations)
Community
(social capital,
Health Care)
Well-Being
Poverty
(Duration
& Depth) + 17

21. So – if we know what we know about vulnerability (and adversity)
what can we do to nurture resilience (and a protective environment?)

22. ASSESSMENT 22

23. Diagnosis Intervention
Assessment
Assessment is the process of collecting and evaluating relevant information about the person, the causes and level of ID, the psychological functioning, the development, the psychological characteristics, the physical health, the social, interpersonal and physical environment, and the behavioral pattern.
Diagnosis Intervention
Supporting Complex Needs – A pratical guide for supporting staff working with people with a learning disability who have mental health needs, Estia Centre 23

24. Assessment of the Environment
Signs and Symptoms
The Person
Assessment of the Environment
Historical and current clinical records
Interview with person
Information from caregivers (professionals and families )
Direct behaviour observation
Recognise potential symptoms of mental or physical illness
Formal and standardised procedures
Biological Characteristics
Psychosocial aspects
Physical disorders
Psychiatric disorders
Functional problems
Communication ( skills )
The impact of life events and transition
Physical environment
Significance of the person for the environment
Transitional events ( daily centre, residential or family )
Pedagogical problems
Social and religious aspects
Risk factors
Cultural aspects
Life event of Families
Inclusion
Stigma
Supporting Complex Needs – A pratical guide for supporting staff working with people with a learning disability who have mental health needs, Estia Centre 24

25. DIFFICULTIES WITH THE DIAGNOSTIC PROCESS IN ID
What the persons say they are experiencing
Difficulties in communication skills or language impairment
Even in verbally competent, auditory hallucinations are the only first-rank symptom that can be detected
What others say about them and how they are seen to behave
A confounding factor is the belief that such problems are inevitable and unchangeable. This means that help is not sought.
‘Diagnostic overshadowing’ whereby someone’s general mental state or behaviour is attributed to the fact that he or she has an intellectual disability1
History of complaint
The development, for example, of maladaptive behaviours, increasing withdrawal, or changes in a person’s state of general well-being may be a marker for a possible mental health problem (baseline exaggeration).
Establishing a baseline and recording changes are central to the diagnostic process
The presentation of symptoms
Costello H. and Bouras N. Assessment of mental health problems in people with intellectual disabilies. Isr J Psychiatry Relat Sci Vol 43 No. 4 (2006):
Mental health and intellectual disabilities addressing the mental health needs of people with id. Report by the Mental Health Special Interest Research Group of the IASSID to the World Health Organisation. Final version – September, 2001
1. Reiss S, Syszko J. Diagnostic overshadowing and professional experience with mentally retarded persons. Am J Ment Deficiency 1993;87:396–402.

26. COMPLEXITY OF PHENOMENOLOGY OF PSYCHIATRIC DISORDERS IN ID
Level of cognitive ('intellectual distortion'1), communicative, physical and social functioning
Level of development ('developmental appropriateness'2)
Interpersonal, cultural and environmental influences (psychosocial masking3)
'ID overshadowing'4
Differentiate between psychiatric symptoms and signs and symptoms of underlying brain damage
Atypical or masked presentation
Aggression, screaming, maladaptive behaviours, etc.
Neuro-vegetative vulnerability
Somatic complaints, changes in circadian rhythm, NV dystonias
'Cognitive disintegration'3
Coping impairment and lower threshold
1. Sovner R, DesNoyers Hurley A. Four factors affecting the diagnosis of psychiatric disorders in mentally retarded persons. Psychiatric Aspects of Mental Retardation Reviews 1986; 5: 45–48.
2. Cooper SA., Salvador-Carulla L. (2009) Intellectual Disabilities. in I.M. Salloum and J.E. Mezzich Eds. Psychiatric Diagnosis: Challenges and Prospects. John Wiley & Sons, Ltd
3. Sovner R. Limiting factors in the use of DSM-III criteria with mentally ill/ mentally retarded persons. Psychopharmacol Bull 1986; 24:1055–1059.
4. Reiss S, Syszko J. Diagnostic overshadowing and professional experience with mentally retarded persons. Am J Ment Deficiency 1993;87:396–402.

27. INTERVENTION 27

28. Intervention Assessment Diagnosis Person-centred context
Respect of the person’s rights
Multidisciplinary team
Early intervention when signs are present
Partnership with families and other carers
Detailed information concerning the nature and outcome of previous interventions
Detailed information concerning the nature and outcome of next interventions
Psychotherapeutic and pharmacotherapeutic interventions delivered in combination with other interventions
Proactive strategies address the goodness of fit between the person and their environment
Communication intervention (increasing and teaching ways of communication )
Assessment Diagnosis

29. WHEN TO CONSIDER MEDICATION
Risk/ harm/ distress to self/ others/ property
Failure of other interventions
Success of medicinal intervention before
Underlying mental disorders/ anxiety/ ASD/ ADHD etc.
As an adjunct to other measures
Person/ carer choice
Severe consequences of the behaviour
Deb S., Kwok H., Bertelli M., et al. International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities. World Psychiatry, 2009; 8(3):

30. KEY PROCESSES ASSOCIATED WITH USING MEDICATION TO MANAGE PROBLEM BEHAVIOURS IN ADULTS WITH IDD
Deb S., Kwok H., Bertelli M., et al. International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities. World Psychiatry, 2009; 8(3):

31. BPS Model Sensations,… Here and Now Mental Health medical factors
Psychological
factors
Environmental
Developmental
Psychiatric
Disorders
Biological and
medical
Here and Now
sensations,…
Thoughts,…
Feelings,…
Motivation,…
Environment
and social
Sensations,…
Condition:
- Instigating.
- Processing.
- Maintaining.
Mental
Health
medical factors

32. Comprehensive Model
The Person (biological and psychosocial factors, and medical, functional and psychiatric problems )
Interaction
(Behaviour)
The Environment (material, personal, social, pedagogical and cultural factors, system characteristics and significance of the involved person)
H-ID Practice Guidelines and Priciples – Assessment, Diagnosis, Treatment, and Related Support Services for Persons with Intellectual Disabilities and Problem Behaviour 32

33. RBC
RBC – A strategy for rehabilitation equalization of opportunities, poverty reduction ans social inclusion of people with disabilities. Joint position paper 2004

34. STRESS MANAGEMENT
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35. HOW CAN WE PREVENT STRESS? HOW CAN WE TREAT STRESS?
STRESS MANAGEMENT
WHAT IS STRESS?
HOW CAN WE PREVENT STRESS?
HOW CAN WE TREAT STRESS?

36. STRESS
A dynamic response process to an environmental change aimed at reaching a balance between the challenges posed and the available resources of the individual to cope with it.

37. THE STRESS CURVE Fatigue Extenuation Healthy Tension Collapse
Performance
Fatigue
Extenuation
Healthy Tension
Collapse
Activation

38. TYPES OF STRESS Environmental challenge:
LIFE EVENTS (Hassles and Hazards) vs TRAUMA
Individual’s response
PHYSICAL versus PSYCHOLOGICAL
Type of response:
EUSTRESS versus DISTRESS
Duration:
ACUTE versus CHRONIC

39. Psychological Distress
A condition or feeling experienced when a person perceives that demands exceed the personal and social resources the individual is able to mobilise
(Lazarus, 1999)

40. NEGATIVE EMOTIONS PSYCHOLOGICAL DISTRESS Stress Vulnerability
PERSONALITY
Neuroticism
Introversion
Stress Vulnerability
MENTAL DISORDERS
Depression
Anxiety
Adjustment disorders
Other stress related disorders

41. SIBIU DECLARATION
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42. TRansfer of INNOvation on Dual Diagnosis CHARTER OF CONCLUSIONS
TRINNODD
TRansfer of INNOvation on Dual Diagnosis
CHARTER OF CONCLUSIONS
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43. Facts Disability Policy is a Human Right Policy .
Prevalence of Mental Health problems is higher in people with ID
This can lead to more segregation and inequality of opportunity
There is higher bio-psycho-social vulnerability
Conclusion: Mental Health and Disability policy should emphasize prevention and treatment of mental health problems of this population in order to improve their quality of life! 43

44. Outcomes
Inclusive collaboration between general mental health services and general services for people with ID should facilitate a life long prevention, intervention and after-care for people with intellectual disabilities.
Only when indicated, complementary specialised support should be organised in addition by multidisciplinary services / teams. 44

45. (Article 25) Health Plans
These outcomes should be part of all National strategic (mental) health plans for people with ID including all stakeholders from the field (users included), based on UN‘s 2006 Declaration on Rights for People with Disability
(Article 25) 45

46. Availability of health data & statistics
Data on mental health disorders and problem behaviour in ID are not always available in national health reports.
This may lead to:
inadequate structures (services) in the health (mental health) system for this population,
a lack of specialist professionals,
higher education programmes that fail to assure high standards in training for professionals about mental health and problem behaviour in people with ID,
a lack of research on mental health for people with ID.

47. Evaluation and Research
Research policy should create a supportive environment that will enable evaluation and research in the field of (mental) health of people with ID. 47

48. Staff Training
Attitude
Enabling staff to be understanding, receptive, creative and patient centred in their approach to bringing about change, not to be “conditioned” to standard and outdated responses 48

49. Staff Training High quality services
need staff who are well trained in mental health and intellectual disability issues with:
specific information & knowledge
specific skills and attitudes
active participation in a multidisciplinary environment
Staff need special support to cope with both the mental health issues of PwID and their own vulnerability

50. specific information & knowledge
Information about a framework of quality of life
Minimum knowledge of mental health issues
Minimum knowledge of observation and evaluation tools

51. specific skills and attitudes
Ability to engage in reflective practice
Ability to work with supervision – either individually or in peer groups

52. active in participation in a multidisciplinary environment
Open to exchange of different approaches and expertise
Open to exchange between staff with different qualifications
Understand the importance of interaction between practice, theory and research

53. Life-span approach in supporting people with ID in a holistic way
Ongoing Processes
Life-span approach in supporting people with ID in a holistic way
Lifelong learning approach for staff training concepts
Lifelong support for professionals, families and user